Time to Change the UTI Paradigm

by Timothy Gieseke MD, CMD

Our pursuit of sterilizing the urinary tract to prevent serious UTI complications in elderly patients is a concept that no longer stands the test of time.  Multiple studies have shown that asymptomatic bacteriuria is present in 30-50% of older women and that treatment of this condition with antibiotics does not alter the rate of future serious systemic infections.  The traditional argument that a delirious elder has a UTI until proven otherwise typically delays a search for the many other common causes of delirium such as dehydration, new drug, unrecognized pain, etc.  In addition, before a UA is done, you have a huge chance of asymptomatic bacteriuria being misidentified as a symptomatic UTI.  Experts estimate that 25-75% of antibiotics prescribed in nursing homes do not meet clinical guidelines for appropriate prescribing.

The most common infection leading to inappropriate antibiotic prescribing is for UTIs with up to 1/3 of prescriptions for asymptomatic bacteriuria.  The potential for harm is great with risk for selecting antibiotic resistant infections, acquiring symptomatic Clostridium difficile infection, and multiple serious antibiotic side effects.  Now a large 2 year study from Ontario, Canada, shows that serious adverse effects are not only common for those receiving antibiotics, but also for other residents in the nursing homes.  In homes with high antibiotic usage, there was a much greater risk of residents who had not received antibiotics experiencing a serious adverse consequence.  (Please see the link to a summary of this article below.)

At our annual CALTCM meeting in April, Dr. Peter Patterson challenged us to consider the fact that our bodies have a huge microbiome at any one time and that the vast majority of the time, this is vital and beneficial to our existence.  In patients with recurrent C. diff. the value of fecal transplants to restore a healthy GI flora has been well documented.

He recommended:   Diagnosing a UTI on the basis of revised McGeer Criteria:

a.     A UA with pyuria and minimal epithelial cells that only grows out 1 organism on culture

b.     A consistent clinical picture that includes at least 1 of the following:

i. Acute dysuria
ii. Fever and or Leukocytosis and 1 of the following
1.     Acute CVA pain or tenderness
2.     Suprapubic pain or tenderness
3.     Gross hematuria
4.     New or marked increase in incontinence, urgency, or frequency.
iii. If absence of fever or leukocytosis, than at least 2 of 1-4 above.

In California, proposed legislation (SB 361) will require DPH to develop guidelines for antibiotic stewardship for nursing homes by July 2016.  (See link below.)

Improving the appropriate use of antibiotics will require us to manage our confused patients differently. Clinicians will need to quickly and comprehensively assess a patient who is more confused for the full spectrum of potential causes.  In addition, a period of close observation for UTI manifestations while providing optimal hydration may result in clearance of the confusion without the use of antibiotics.

Our progress in better managing UTIs may be better measured by going beyond reports on the number of positive cultures and antibiotics prescribed, to categorizing antibiotic use not meeting the McGeer criteria, as potentially inappropriate while measuring for times when a delay in use of antibiotics had an adverse consequence.

This is a real paradigm shift that will require not only educating our staff, but also our patients and their families. 

At CALTCM, we look forward to hearing your success stories in future WAVE submissions.  It’s not too early to plan a performance improvement Poster on this subject for next year’s annual meeting.  A project like this may fulfill the CMS expectation for 1 of 3 QAPI projects per year.

JAMA Article: Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents

SB 361 Senate Bill